Kim Yen Thi Vu

Early depression screening is feasible in hospitalized stroke patients.

Background and Purpose Post-stroke depression (PSD) is common but is not routinely assessed for in hospitalized patients. As a Comprehensive Stroke Center, we screen all stroke inpatients for depression, though the feasibility of early screening has not been established. We assessed the hypothesis that early depression screening in stroke patients is feasible. We also explored patient level factors associated with being screened for PSD and the presence of early PSD. Methods The medical records of all patients admitted with ischemic stroke (IS) or intracerebral hemorrhage (ICH) between 01/02/13 and 15/04/13 were reviewed. A depression screen, modified from the Patient Health Questionnaire-9, was administered (maximum score 27, higher scores indicating worse depression). Patients were eligible if they did not have a medical condition precluding screening. Feasibility was defined as screening 75% of all eligible patients. Results Of 303 IS and ICH inpatients, 70% (211) were eligible for screening, and 75% (158) of all eligible patients were screened. More than one-third of all patients screened positive for depression (score > 4). Women (OR 2.06, 95% CI 1.06–4.01) and younger patients (OR 0.97, 95% CI 0.96–0.99) were more likely to screen positive. Screening positive was not associated with poor discharge/day 7 outcome (mRS > 3; OR 1.45, 95% CI 0.74–2.83). Conclusions Screening stroke inpatients for depression is feasible and early depression after stroke is common. Women and younger patients are more likely to experience early PSD. Our results provide preliminary evidence supporting continued screening for depression in hospitalized stroke patients.

Identification and Characterization of Proteins Involved in Nuclear Organization Using Drosophila GFP Protein Trap Lines

Background Strains from a collection of Drosophila GFP protein trap lines express GFP in the normal tissues where the endogenous protein is present. This collection can be used to screen for proteins distributed in the nucleus in a non-uniform pattern. Methodology/Principal Findings We analyzed four lines that show peripheral or punctate nuclear staining. One of these lines affects an uncharacterized gene named CG11138. The CG11138 protein shows a punctate distribution in the nuclear periphery similar to that of Drosophila insulator proteins but does not co-localize with known insulators. Interestingly, mutations in Lamin proteins result in alterations in CG11138 localization, suggesting that this protein may be a novel component of the nuclear lamina. A second line affects the Decondensation factor 31 (Df31) gene, which encodes a protein with a unique nuclear distribution that appears to segment the nucleus into four different compartments. The X-chromosome of males is confined to one of these compartments. We also find that Drosophila Nucleoplasmin (dNlp) is present in regions of active transcription. Heat shock leads to loss of dNlp from previously transcribed regions of polytene chromosome without redistribution to the heat shock genes. Analysis of Stonewall (Stwl), a protein previously found to be necessary for the maintenance of germline stem cells, shows that Stwl is present in a punctate pattern in the nucleus that partially overlaps with that of known insulator proteins. Finally we show that Stwl, dNlp, and Df31 form part of a highly interactive network. The properties of other components of this network may help understand the role of these proteins in nuclear biology. Conclusions/Significance These results establish screening of GFP protein trap alleles as a strategy to identify factors with novel cellular functions. Information gained from the analysis of CG11138 Stwl, dNlp, and Df31 sets the stage for future studies of these proteins.

Video-based educational intervention associated with improved stroke literacy, self-efficacy, and patient satisfaction

Background and purpose Interventions are needed to improve stroke literacy among recent stroke survivors. We developed an educational video for patients hospitalized with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH). Methods A 5-minute stroke education video was shown to our AIS and ICH patients admitted from March to June 2015. Demographics and a 5-minute protocol Montreal Cognitive Assessment were also collected. Questions related to stroke knowledge, self-efficacy, and patient satisfaction were answered before, immediately after, and 30 days after the video. Results Among 250 screened, 102 patients consented, and 93 completed the video intervention. There was a significant difference between pre-video median knowledge score of 6 (IQR 4–7) and the post-video score of 7 (IQR 6–8; p<0.001) and between pre-video and the 30 day score of 7 (IQR 5–8; p = 0.04). There was a significant difference between the proportion of patients who were very certain in recognizing symptoms of a stroke pre- and post-video, which was maintained at 30-days (35.5% vs. 53.5%, p = 0.01; 35.5% vs. 54.4%, p = 0.02). The proportion who were “very satisfied” with their education post-video (74.2%) was significantly higher than pre-video (49.5%, p<0.01), and this was maintained at 30 days (75.4%, p<0.01). There was no association between MoCA scores and stroke knowledge acquisition or retention. There was no association between stroke knowledge acquisition and rates of home blood pressure monitoring or primary care provider follow-up. Conclusions An educational video was associated with improved stroke knowledge, self-efficacy in recognizing stroke symptoms, and satisfaction with education in hospitalized stroke patients, which was maintained at 30 days after discharge.

Predictors of Percutaneous Endoscopic Gastrostomy Placement in Acute Ischemic Stroke

BACKGROUND Dysphagia is a common complication of stroke and can have a lasting impact on morbidity and mortality; yet there are no standards to guide dysphagia management in stroke patients. We assessed predictors of percutaneous endoscopic gastrostomy (PEG) placement in an ischemic stroke cohort and sought to determine the utility of an objective scale in predicting PEG placement in a high-risk sub-set. METHODS Consecutive cases of ischemic stroke were retrospectively, identified and demographic and clinical variables were collected. Penetration-Aspiration (PAS) scores (1-2 normal; 3-5 penetration; 6-8 aspiration) were calculated for patients undergoing Fiberoptic Endoscopic Evaluation of Swallowing (FEES) or Modified Barium Swallowing Studies (MBSS). Multiple logistic regression analysis was used to assess predictors of PEG placement. RESULTS Among 724 patients, 131 underwent PEG placement. In univariate analysis of the overall cohort, sex, age, insured payer status, arrival National Institute of Health Stroke Scale (NIHSS), NIHSS level of consciousness severity, NIHSS dysarthria severity, diabetes mellitus, and prior International Conference for Harmonization (ICH) were all significantly associated with PEG placement. Among 197 high-risk patients undergoing FEES or MBSS, the multivariate logistic regression analysis showed that PAS scores 6-8 versus 1-2 (odds ratio [OR] 13.2; 95% confidence interval [CI] 4.58, 38.2), PAS score 3-5 versus 1.2 (OR 33.8; 95% CI 11.6, 98.3), Hispanic race (OR, 5.73; 95% CI 1.82, 18.0), male sex (OR, 2.59; 95% CI 1.05, 6.34), and arrival NIHSS (OR, 1.11; 95% CI 1.05, 1.18) were associated with PEG placement. CONCLUSIONS Use of an objective dysphagia scale simplified the prediction model among acute ischemic stroke patients undergoing instrumental assessments of dysphagia with FEES or MBSS. Male sex and Hispanic race were also significantly associated with PEG placement in this analysis. These findings support the need for rigorously designed prospective studies to assess biological and social factors that influence PEG placement and to determine, how to best evaluate and manage patients with dysphagia.

Telemedicine-guided education on secondary stroke and fall prevention following inpatient rehabilitation for Texas patients with stroke and their caregivers: a feasibility pilot study

Introduction The aftermath of stroke leaves many consequences including cognitive deficits and falls due to imbalance. Stroke survivors and families struggle to navigate the complex healthcare system with little assistance posthospital discharge, often leading to early hospital readmission and worse stroke outcomes. Telemedicine Guided Education on Secondary Stroke and Fall Prevention Following Inpatient Rehabilitation feasibility study examines whether stroke survivors and their caregivers find value in telerehabilitation (TR) home visits that provide individualised care and education by a multidisciplinary team after discharge from inpatient rehabilitation. Methods and analysis A prospective, single arm, pilot study is designed to evaluate the feasibility of weekly TR home visits initiated postdischarge from inpatient rehabilitation. Newly diagnosed patients with stroke are recruited from a Houston-based comprehensive stroke centre inpatient rehabilitation unit, loaned an iPad with data plan and trained to use information technology security-approved videoconferencing application. After hospital discharge, six weekly TR home visits are led by rotating specialists (pharmacist, physical/occupational therapist, speech therapist, rehabilitation physician, social worker, geriatrician specialised in fracture prevention) followed by satisfaction survey on week 7. Specialists visually assess patients in real time, educate them on secondary stroke and fall prevention and suggest ways to improve function including direct medical interventions when indicated. Primary outcomes are proportion of eligible patients consenting to the study, participation rate in all six TR home visits and satisfaction score. The study started 31 December 2015 with plan to enrol up to 50 patients over 24 months. Feasibility study results will inform us as to whether a randomised controlled trial is warranted to determine efficacy of TR home visit intervention in improving stroke outcomes. Ethics and dissemination Ethics approval obtained by the Institutional Review Board (IRB), Committee for the Protection of Human Subjects, IRB number: HSC-MS-14–0994. Study results will be submitted for publication in a peer-reviewed journal.

1251: RAPID CRITICAL CARE TEAM RESPONSE IN DECOMPENSATING NEUROLOGICALLY INJURED PATIENTS

Learning Objectives: Rapid response teams (RRT) have been created to quickly respond to patients who deteriorate outside of the ICU. Critical care physicians and nurse, should not be bound by the walls of the ICU, but rather should respond to critically ill patients wherever they may be. Our RRT includes neurocritical care physicians and neurocritical care nurses who respond to RRT activations (RRTa) throughout the neuroscience floors of the hospital. To improve quality we review all RRTa in a multidisciplinary group to examine the root cause of each RRTa with a goal to improve patient outcomes. We performed a quality improvement project to examine the risk factors, causes and clinical outcomes of patients admitted to neurology/neurosurgery who require RRTa. Methods: This is a quality improvement project performed at an academic tertiary care trauma and stroke center. Prospectively collected data from RRTa which occurred in patients admitted to the neuroscience service from November 2015 to June 2016 were analyzed. Results: 95 RRTa occurred during this period. Average age was 62 and 45% were female. The most common admitting diagnosis was stroke (50%) followed by traumatic brain/spine injury (14%) and seizures (8%). 9% of patients had more than one RRTa. RRTa occurred on average 8 days after hospitalization. The most likely reason for RRTa was respiratory distress and hypoxia (38%), followed by hypotension (16%) and neurologic change (15%). The most common RRTa diagnosis was aspiration pneumonia (16%). The majority of the time (55%) patients required transfer to an ICU; 13.8% were transferred up to a step-down level of care; and 21% remained on the clinical unit of the RRTa. RRTa occurred equally during the day and night. 18% of patients died or were transitioned to comfort measures/ hospice, 14% were transferred to a long term acute care facility, 21% went to rehab and 28% were discharged home. Conclusions: RRTa are associated with 18% in-hospital mortality rate. The most common cause of a RRTa is from respiratory distress. Processes to address the most common causes of RRTa should be implemented. 1252

587: OUTCOMES AFTER PERCUTANEOUS ENDOSCOPIC GASTROSTOMY IN NEUROCRITICAL CARE PATIENTS

Learning Objectives: Inability to swallow without aspiration is a common issue in the neurologically critically ill patient. Although it is common practice to place percutaneous endoscopic gastrostomy tubes (PEGs) in patients with prolonged swallowing dysfunction there is a paucity and sometimes conflicting information about clinical outcomes after PEGs in the critically ill population. PEG complications can range from minor to major complications and estimated to range from 16-75%. We examined rates of complications of PEG placement and time to return of swallowing function. Methods: This is a retrospective study examining all patients admitted to a neuroscience intensive care unit who had a PEG tube placed after a swallowing study was performed from January 2016 to March 2016. Complications including acute post-surgical bleeding with 24 hours, chronic GI bleeding from PEG, inadvertent dislodging of PEG, PEG infections and additional surgical procedure due to PEG complication. We examined time to recovery of swallowing function. Results: 80 patients were included. Average age was 68 years (SD16). 65(81%) had a diagnosis of ischemic or hemorrhagic stroke and 15(19%) had traumatic brain or spinal cord injury. PEGs were placed on average 9.2(SD5.5) days into the hospitalization and patients had an average of 8.4(SD8) days after PEG placement. The total number of patients who experienced a complication for PEG placement was 15(19%). The most common complications were PEG infections, 6(7.5%) and GI bleeding, 6(7.5%). There were 2(2.5%) inadvertently displaced PEGs and 2(2.5%) surgical procedures needed from PEG complications. Out of the complications 4(5%) resulted in death, 2(2.5%) required surgical intervention. 28 patients had recovery of swallowing with a median of 17 days. 6 patients had return of swallow within 10 days of PEG placement. Conclusions: In the neurologically critically ill, PEG tubes were associated with a 19% complication rate, with an 8% risk of severe complications. Intensivists recommending PEGs in neurologically ill patients should be aware of the potentially high rates of complications.